Tag Archives: hospitals

In this post, New Generation Thinker Dr Sam Goodman (Bournemouth University) reflects on the role female nurses played in WW1, and on how the reality is embellished in historical dramas such as Downton Abbey.

In this time of renewed focus on the First World War, both in a commemorative and also a cultural sense, we are confronted regularly with the experience and imagery of suffering. Arguably, TV and film productions that dramatize the war have a responsibility to depict its various horrors, from the squalor of the dugouts through to the trauma of violent injury in battle, and very few shy away from doing so. Of equal importance as these male perspectives on war in the trenches though is the female experience of conflict. In many ways, the roles played by women in the First World War offer more varied accounts than their male counterparts, as they include the stories of those women in Britain either employed in industry or waiting for return of a loved one, or those overseas working in a range of capacities in support of the military. Of all of these roles, one of the most recurrent is that of the nurse. The nurse and her experiences are a staple of popular fiction, and have proved evident in recent televisual productions such as The Crimson Field and Downton Abbey, as well as the film adaptation of Vera Brittain’s memoir, Testament of Youth.

Lady Sybil Crawley as a nurse in Downton Abbey

The representation of nursing in these productions typically follows a similar narrative pattern – a young and headstrong woman desires greatly to contribute to the war effort often in defiance of her parents’ wishes, her class status, or some other obstacle. She overcomes initial resistance and gets her wish but her ideals and illusions are shattered by the brutal reality of modern warfare, leaving her emotionally scarred but ultimately changed for the better as a result of her experiences. This is certainly the case with a character like Sybil Crawley from Downton Abbey, whose growing consciousness of the difference between her parents’ values and her own manifests itself successively in daring fashion choices, romance with the family chauffeur, and then a decision to join the Voluntary Aid Detachment (VAD) in 1916. Sybil’s actions cause all manner of narrative tension but her compassion and dedication to helping others ultimately convinces her parents that nursing is a respectable occupation befitting her social standing. Sybil’s experience appears to deliberately echo Vera Brittain’s journey in Testament of Youth, though does not, as in Brittain’s case, result in a life-long support for pacifism.

Whilst Downton is entirely fictitious and some liberties are taken with the events in Brittain’s memoir in the adaptation, the image of the ‘daring’ or ‘rebellious’ nurse that these texts project is not one created with dramatic licence. The history of nursing had always owed a great deal to the efforts of driven and determined women. At the beginning of the First World War, a professional, organised nursing service was still a relatively recent development within the world of the armed forces, and had only just begun to gain the respectability it would later acquire. A generation earlier and a professional, trained nursing service was a novelty, and a near practical unknown. Until the late nineteenth-century, nursing was mainly the work of religious orders or organisations, or relied on the voluntary actions of individuals; in the Crimean War of 1853-56, women such as Mary Seacole and, of course, Florence Nightingale would be celebrated for their charitable actions, conducted without any organisational support, and little interest from the military command they were aiding. Subsequently to the Crimea, nurses such as Nightingale and Ethel Gordon Fenwick would be instrumental in developing rigorous and professionalised training programmes and a national register for nurses within the United Kingdom. These schools later became affiliated with hospitals and, as a result of the efforts of Fenwick and others, as well as influential royal support, nursing grew into the organised body on which the modern service is based. With the founding of the Army Nursing Service (ANS) in 1881, the Imperial Military Nursing Service (QAIMNS) in 1902, the British Army’s First Aid Nursing Yeomanry (FANY) in 1907, and the VAD in 1909 nursing became more widely known and respected, and these services would provide crucial medical care when war came in 1914.

Of course the romanticised ideal of the Edwardian woman escaping the strictures of the household for a life of emancipation and liberation in the service of nursing owes a good deal to the recruitment drives mounted throughout the war. The image of the nurse created by the war was one of selflessness and sacrifice, determined to provide care no matter what the personal risks may be, a perception fuelled by the public feeling over the execution of Edith Cavell for espionage in 1915. Of course far more Edwardian women were already in work before the outbreak of war than most people assume, and the virtuous image of wartime nursing was ruthlessly satirised in Blackadder Goes Forth (1986) in which Miranda Richardson’s Nurse Mary Fletcher-Brown smokes, drinks and dryly declares that ‘it’s good to have someone healthy to talk to for a change’. However, for some women, service in VAD, QAIMNS, or FANY did nonetheless equip them with skills and experience, and instil confidence that they otherwise would not have had opportunity to acquire. Any fictional focus on these experiences, even if they do bend the truth a little for dramatic effect, plays an important part in remedying the notion that the First World War took place only in the trenches.

Along the lines of evacuation, wounded men encountered men and women serving in caring roles. In this guest post, Dr Jessica Meyer explores what the organisation and staffing of medical establishments in war meant for gender and gender roles.

For women, wartime medicine could, at one level, mean greater opportunity. For doctors like Elsie Inglis, who led the Scottish Women’s Hospital, the desperate need for medical professionals at or near the front line provided the opportunity to demonstrate hard-won skills. Doctors such as Inglis and her staff had the opportunity to prove that they were equal to their male colleagues in terms of their courage and resourcefulness as well as their skills. For professional nurses, the war provided an even greater opportunity to lay claim to a professional identity through recognised service with both the military nursing services and the British Red Cross. For unskilled middle class women, volunteering with the Voluntary Aid Detachments and social caregiving units such as the YMCA or train greeting committees was a socially sanctioned form of war service which took them beyond the confines of domesticity. They could learn new skills, experience adventure, and even travel abroad. Finally, for working class women, general service with the British Red Cross provided a form of war service that was safer, if considerably less well reimbursed, than munitions work.

Used with the permission University of Leeds Special Collections, Liddle/MUS/AW/118’

Yet women’s experiences of medical caregiving in the war was not simply a story of female liberation and the establishment of professional female identities. Indeed, the struggle to establish such an identity was, in some ways, severely limited by the war. The Scottish Women’s Hospitals were not employed by the British military but served instead with allied nations, including the French, Belgian and Serbian militaries. After the war, many continued in medicine until marriage, but without the recognition that was accorded to their male colleagues of the Royal Army Medical Corps.

For professional nurses, the war presented an opportunity and a challenge. The service of volunteers, who were valorised not simply as nurses but as volunteer nurses, threatened military nurses’ claims to a specifically professional identity. If nursing was something that could be done effectively voluntarily, then why accord special recognition to those who undertook it as a career? The power of this challenge is reflected in the fact that cultural memory of First World War nursing is often dominated by the eloquent voices of VADs such Vera Brittain rather than the more restrained professionalism of military nurses.

A similar conflict can be seen in the opportunity for women to train in medical roles previously reserved for men, such as anaesthetists and pharmacists. On the one hand this provided professional opportunities for women to gain previously unavailable expertise. On the other hand, these roles were under the authority of the always male surgeon or hospital Commandant. At the same time, the increasing number of women in medical care strengthened pre-existing cultural links between caregiving and femininity. In a society where the marriage bar in most professions would exist for another half a century, this served to depress the status of medical care as much as it improved female emancipation. It is arguable that the relatively low financial value accorded to hospital carers today can be traced in part to the rise of female dominance of hospital care during the First World War.

And what of the men engaged in caregiving roles? For medical officers, the influx of civilian professionals served to enhance the professional identity of a service that had, before the war, struggled to define its status within the military. The actions of men such as Noel Chavasse, one of two medical officers to win not only a VC but also a bar, helped the officer ranks of the corps lay claim to a heroic wartime identity despite being non-combatant.

Stretcher bearers similarly were able to define their work as heroic. Forced to face the terrors of the front line and come under attack without even carrying a weapon, stretcher bearer heroism was built on the image of immense stoicism in the face of danger. In a conflict where endurance was increasingly key to definitions of the soldier hero, their work under fire was increasingly a source of admiration for their combatant comrades.

Medical orderlies, by comparison, had a far harder struggle in defining themselves as masculine. Tent orderlies serving overseas with field ambulances and Casualty Clearing Stations could and did come under shellfire. Many also volunteered as stretcher bearers, using the role to lay claim to the qualities of endurance and self-sacrifice that attached themselves to their colleagues. Those serving in Base and, even more so in Home hospitals, found themselves labelled as ‘Slackers in Khaki’ and mocked as the diminutive ‘orderlim’. This was an identity that orderlies never appear to have fully shaken off. The manpower crisis meant that men were increasingly ‘combed out’ for combatant duty to be replaced by men too unfit for front line service. These men were unable to fulfil definitions of heroism which privileged physical fitness, but having lost that fitness through war service, their masculinity was less open to direct question.

In 1919 the RAMC was recruiting for men who wished to ‘learn a useful occupation which may help you in civilian life’, recognition that such service could help men achieve the appropriate masculine identity of provider as well as that of military hero. While caregiving may have become an increasingly feminine occupation, particularly in diluted hospitals, by the end of the war the RAMC serviceman was able to define not only his wartime but his postwar role as appropriately masculine.

In this guest blog, Caroline Nielsen describes how vulnerable patients were displaced from hospitals to make way for the casualties of war.

In a recent post for this blog, Dr Jessica Meyer discussed how wounded and sick soldiers were evacuated from the frontlines to large specialized hospitals in Britain. Images of these war hospitals and their military patients have appeared in publications as part of the centenary commemorations. These institutions have even been the subject of popular TV dramas, such as Downton Abbey, The Wipers Times, and The Crimson Fields. But the creation of these life-saving institutions had a hidden cost: the forced displacement of around 12,000 of the most vulnerable people in British society. This was because twenty-four of Britain’s largest war hospitals were requisitioned asylums for the mentally ill and those with learning disabilities.

Asylums and the War
The British military authorities were under considerable pressure in late 1914. There were simply not enough hospital beds in Britain to accommodate the ever-growing number of allied war casualties. Numerous patriotic individuals and organisations voluntarily opened their doors to soldier-patients, donating their time, money, and property to the war effort. But it was simply not enough. A drastic and ambitious scheme was developed to ensure that the nation remained fighting fit. Recovering soldiers needed beds but they also needed spacious grounds, recreational areas and sports fields to aid their recovery. Only a small number of institutions had all of these facilities already in place: residential schools, workhouses and the largest of them all, lunatic asylums. There were only two problems: the pre-existing large population of vulnerable patients and the stigma attached to them.

Every county in England and Wales had a lunatic asylum. Run by local committees overseen by the Government’s centralized Board of Control, these institutions offered residential care to a large population of men, women and children. There were over 102 psychiatric asylums in England and Wales in 1914. Over 108,000 men, women and children lived permanently in these institutions. This meant that each county and borough asylum cared an average of 1000 patients at any one time (Sarah Rutherford, The Victorian Asylum, 2011).

Asylum patients had a wide range of conditions, many of which would not fit with modern understandings of mental illness. As well as caring for those with depression, anxiety and delusions, asylums nursed those with long-term or degenerative conditions like epilepsy, tuberculosis, liver disease, alcoholism, and syphilis. A significant proportion of patients were elderly and frail, moved from out of their homes when they started to experience the disorientating symptoms of dementia. It was not uncommon to find those with learning disabilities living permanently in asylums (for example those with Down’s syndrome or who would now be placed on the autistic spectrum). It is important to stress that the majority of those with learning disabilities in the early twentieth century continued to live with their extended families. While some patients were sent by their families to these institutions, others were referred there by social welfare authorities: by doctors, charity workers, the Board of Education, or by the Guardians of the Poor who oversaw workhouses. Going into a workhouse or insane asylum carried a huge social stigma. But for the most impoverished, sick and desperate, they offered the only chance of free medical care.

The Asylum War Hospital Scheme, 1915-1919
Faced with mounting casualties, the British War Authorities approached the Board of Control for permission to empty a small number of asylums. Patients were either to return to their families or be transferred into different institutions. 9 asylums were initially selected, with others gradually added into the scheme whenever more beds were needed. All selected asylums were swiftly renamed as “war hospitals” so that soldier casualties would not be tainted with the stigma of receiving treatment in a lunatic asylum.

The most incredible aspect of the scheme was the speed with which it was carried out. Within 5 weeks of the scheme being confirmed, the selected asylums had been emptied of all but a few of their patients. The official estimate was about 12,000. Only the “gravely ill” [dying] and a few “quiet useful insane” men were allowed to stay on. The “useful” patients were to work as gardeners. (Board of Control, Official History of the War Asylum Hospitals, 1920). The insane were not even given the reassurance of familiar staff. Asylum nursing staff were requisitioned for the war effort along with the furniture.

Unsurprisingly, the immediate effect on the patients was severe. The official report of the Medical Officer of Norfolk County Asylum (later Norfolk War Hospital) is so shocking that it is worth quoting at length;

The scenes on departure aroused varying emotions in myself, my medical colleagues and the nurses. It was all interesting, some of it most amusing and much sadly pathetic. To not a few the asylum had been their home for many years, some for over fifty years, some since childhood; many even had never been in a railway train … so it will be readily believed that the whole gamut of emotion was exhibited by the patients on leaving, ranging from acute distress and misery, through gay indifference, to maniacal fury and indignation.

Casualties of War
That the Asylum War Hospitals Scheme saved lives is beyond dispute. By 1920, the hospitals had offered specialist care, pioneering treatment and friendship to over 440,000 men from all over the world. Approximately over 38,000 (9%) of these men were psychiatric cases; those suffering from shell-shock, nervous breakdowns, delusions, and sheer terror.

But the War Hospitals came at a terrible cost to the mentally ill and their families. Within 1 year of the first transfers, the Board of Control noticed that patients were dying at a higher rate than usual. Overcrowding had resulted in some of the remaining asylums, facilitating the spread of influenza, pneumonia and tuberculosis. The asylum patients were also subject to rationing and food shortages, weakening an already sickly population. A series of cold wartime winters and a shortage of psychiatric medical professionals only exacerbated the problem.

In its official 1920 inquiry on the War Hospital’s Scheme, the Government reported that the transferred insane should be viewed as quasi casualties of war. Their suffering during the war was immediately and irrefutably comparable to that of “normal” military casualties. The insane deserved respect and sympathy irrespective of the stigma attached to their condition.

This was never to be. In spite of the report-writer’s best efforts, the wartime experiences of the civilian insane were almost immediately forgotten by their communities. The stigma surrounding mental illness and disability meant that discussing their experiences became taboo. No war memorials were raised in the name of these men, women and children. But as the centenary passes, they too should be remembered.

The AHRC and BBC “World War One at Home” project will explore the asylum transfers further in the autumn. Detailed descriptions of the individual asylums can be found in the Board of Control’s official report, entitled “History of the Asylum War Hospitals in England and Wales”, 1920. Regional asylum death statistics can be in Lewis Krammer’s article “The Extraordinary Deaths of Asylum Patients, 1914-18” in the journal Medical History (1992).